Vision and Hearing Program Consent for Services. I, the parent/legal guardian of, give consent Please print name of child

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1 Vision and Hearing Program Consent for Services I, the parent/legal guardian of, give consent Please print name of child for the Cook County Department of Public Health to provide vision and/or hearing screening to my child at his/hers school/day care center. I understand that a copy of the screening results will be provided to me by the school/day care center. The school/day care center will also keep a copy of the results on file. I further understand that I am responsible to provide for all follow- up for findings as recommended by the Cook County Department of Public Health. Parent/Legal Guardian Print Name Date Signature of Parent/Legal Guardian Revised 12/3/2014 VH- 676

2 Programa de control de la visión y audición Autorización para servicios Yo, padre/tutor legal de, autorizo Por favor, escriba el nombre del niño en letra de molde al Departmento de Salud Pública del Condado de Cook a realizer los estudios de control de la visión y/o audición a mi hijo/a en la escuela/guardería infantil a la que asiste. Entiendo que la escuela/guarderia infantil me entregará una copia del resultado de los estudios. Además, la escuela/guardería conservará una copia de los resultados en sus archivos. Entiendo tambien que soy responsible de realizer el seguimiento recomendado por el Departamento de Salud Pública del Condado de Cook a partir de los resultados de los estudios. Padre/tutor legal Nombre en letras de molde Fecha Firma del padre/tutor legal Revised: 12/3/2014 VH- SP- 676

3 Elementary Only School: Date: School Address: Grade: Directory/Teacher: Room #: Child's Name Elementary Only Hearing Vision Age Sex Scrn Re-Scrn Comments Scrn Re-Scrn Comments /24/13 VH-682

4 SCREENING DATE: Vision and Hearing Screening Program (K-6 th Grade Use Only) NAME: PARENT/GUARDIAN: ADDRESS: CITY: PHONE: ZIP: BIRTHDATE: SCHOOL: GRADE: ROOM: ******************************************************************************* I. Muscle Balance: Rescreen Date: Near In Out In Out Far In Out In Out II. Visual Acuity Right Right Left Left III. Hyperopia (+ lens) Right Right Left Left ********************************************************************************* PASSED RESCREEN REFFERED ABSENT ABSENT FOR RESCREEN CNT WEARING GLASSES / UNDER DR S CARE DATE OF LAST EXAM GLASSES REFERRAL COMMENTS: ********************************************************************************* PASS HEARING RESCREEN: RESCREEN DATE: PASS REFERRED: SCREENING TECHNICIAN: VH-669 2/4/2010

5 Vision and Hearing Screening Program (7 th & 8 th Grade Use Only) SCREENING DATE: NAME: PARENT/GUARDIAN: ADDRESS: CITY: PHONE: ZIP: BIRTHDATE: SCHOOL: GRADE: ROOM: ****************************************************************************** Left Middle Right NEAR BRL / / FAR BRL / / Rescreen Left Middle Right NEAR BRL / / DATE: FAR BRL / / ******************************************************************************** PASS RESCREEN REFERRED PASS RESCREEN ******************************************************************************** WEARING GALLSES / UNDER DR S CARE DATE OF LAST EYE EXAM: WEARING CONTACT LENS: DATE OF LAST EXAM: GLASSES REFERRAL / COMMENTS: REFERRAL TO UPDATE PRESCRIPTION AND MEDICAL RECORD: COMMENTS: HEARING SCREENED Passed Rescreen Referred 12/3/2014 VH-668

6 Date VISION EXAMINATION REPORT White Doctor s Referral Canary File Name Birth Date Sex Grade Parent or Guardian Address Phone County Testing Location Testing Agency Tester TEST GIVEN 1. Instrument Used a. Visual Acuity b. Plus Sphere c. Muscle Balance d. Near and Far Binocular Vision e. Other: TO THE DOCTOR TO BE COMPLETED FOLLOWING SCREENING REASON FOR REFERRAL 1. Visual Acuity 2. Plus Sphere 3. Muscle Balance Phoria 4. Near and Far Binocular Vision Fusion SYMPTOMS NOTED 1. Academic Achievement 2. Observable Signs: CHILD WEARING GLASSES OR UNDER CARE Children wearing glasses or under care are not screened as part of the routine vision screening program. Observations by screening technicians possibly indicate the following: Frames broken / too small Two years since last examination Lenses scratched / broken Other: Name (Last) (First) (Initial) TO BE COMPLETED BY EXAMINING DOCTOR UNCORRECTED (1) VISUAL ACUITY DISTANCE (2) BEST CORRECTED VISUAL ACUITY RIGHT LEFT RIGHT LEFT (3) Ocularmotor Assessment (4) Diagnosis PLEASE CHECK IF APPROPRIATE: Treatment recommended Medical Glasses Contact Lenses Other: Corrective lens prescribed Constant Wear Near Vision only Far Vision only May be removed for physical education Visual field restriction Amblyopia exists (5) Comments Muscle imbalance exists Close work may be difficult or cause fatigue Please leave All 3 COPIES ATTACHED FOR THE DOCTOR TO FILL OUT AND RETURN ALL 3 COPIES TO: Cook County Department of Public Health, HSDM 1701 S. 1 st Avenue, 1 st Floor Maywood, Illinois CONSENT OF PARENT OR GUARDIAN I agree to release the above information on my child or ward to appropriate school or health authorities. PARENT OR GUARDIAN S SIGNATURE IDPH V-4 IL Revised Please print or stamp Doctors Address City Date of Examination Preferential seating needed Re-examination advised Six months Twelve months Other: DOCTOR S SIGNATURE Name

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Vision and Hearing Program Consent for Services. I, the parent/legal guardian of, give consent Please print name of child

Vision and Hearing Program Consent for Services I, the parent/legal guardian of, give consent Please print name of child for the Cook County Department of Public Health to provide vision and/or hearing